Common Locations of Gastric Cancer: Review of Research from the Endoscopic Submucosal Dissection Era

Development and validation of a predictive model for submucosal fibrosis in patients with early gastric cancer undergoing endoscopic submucosal dissection: experience from a large tertiary center

BACKGROUND

Submucosal fibrosis is associated with adverse events of endoscopic submucosal dissection (ESD). The present study mainly aimed to establish a predictive model for submucosal fibrosis in patients with early gastric cancer (EGC) undergoing ESD.

METHODS

Eligible patients with EGC, identified at Qilu Hospital of Shandong University from April 2013 to December 2023, were retrospectively included and randomly split into a training set and a validation set in a 7:3 ratio. Logistic regression analyses were used to pinpoint the risk factors for submucosal fibrosis. A nomogram was developed and confirmed using receiver operating characteristic (ROC) curves, calibration plots, Hosmer-Lemeshow (H-L) tests, and decision curve analysis (DCA) curves. Besides, a predictive model for severe submucosal fibrosis was further conducted and tested.

RESULTS

A total of 516 cases in the training group and 220 cases in the validation group were recruited. The nomogram for submucosal fibrosis contained the following items: tumour location (long axis), tumour location (short axis), ulceration, and biopsy pathology. ROC curves showed high efficiency with an area under the ROC of 0.819 in the training group, and 0.812 in the validation group. Calibration curves and H-L tests indicated good consistency. DCA proved the nomogram to be clinically beneficial. Furthermore, the four items were also applicable for a nomogram predicting severe fibrosis, and the model performed well.

CONCLUSION

The predictive models, initially constructed in this study, were validated as convenient and feasible for endoscopists to predict submucosal fibrosis and severe fibrosis in patients with EGC undergoing ESD.

Cross-sectional imaging of gastric cancer: pearls, pitfalls and lessons learned from multidisciplinary conference

Gastric cancer is rising in prevalence associated with high mortality, primarily due to late-stage detection, underscoring the imperative for early and precise diagnosis. Etiology involves an interplay of genetic susceptibilities and environmental factors with a prominent role of Helicobacter pylori infection. Due to its often-delayed symptom presentation, prompt and accurate diagnosis is necessary. A multimodal imaging approach, including endoscopic ultrasound (EUS), multi-detector computed tomography (MDCT), and magnetic resonance imaging (MRI) is critical for accurate staging. Each modality contributes unique advantages and limitations, highlighting the importance of integrating diagnostic strategy. Moreover, multidisciplinary conferences offer a vital collaborative platform, bringing together specialists from diverse fields for treatment planning. This synergistic approach not only enhances diagnostic precision but also improves patient outcome. This review highlights the critical role of imaging in diagnosis, staging, and management and advocates for interdisciplinary collaboration in early detection and comprehensive management of gastric cancer, aiming to reduce mortality.

Helicobacter pylori induces the expression of Lgr5 and stem cell properties in gastric target cells

Helicobacter pylori infection predisposes carriers to a high risk of developing gastric cancer. The cell-of-origin of antral gastric cancer is the Lgr5+ stem cell. Here, we show that infection of antrum-derived gastric organoid cells with H. pylori increases the expression of the stem cell marker Lgr5 as determined by immunofluorescence microscopy, qRT-PCR, and Western blotting, both when cells are grown and infected as monolayers and when cells are exposed to H. pylori in 3D structures. H. pylori exposure increases stemness properties as determined by spheroid formation assay. Lgr5 expression and the acquisition of stemness depend on a functional type IV secretion system (T4SS) and at least partly on the T4SS effector CagA. The pharmacological inhibition or genetic ablation of NF-κB reverses the increase in Lgr5 and spheroid formation. Constitutively active Wnt/β-catenin signaling because of Apc inactivation exacerbates H. pylori-induced Lgr5 expression and stemness, both of which persist even after eradication of the infection. The combined data indicate that H. pylori has stemness-inducing properties that depend on its ability to activate NF-κB signaling.

Gastric Cancer and Intestinal Metaplasia: Differential Metabolic Landscapes and New Pathways to Diagnosis

Gastric cancer (GC) is the fifth most common cause of cancer-related death worldwide. Early detection is crucial for improving survival rates and treatment outcomes. However, accurate GC-specific biomarkers remain unknown. This study aimed to identify the metabolic differences between intestinal metaplasia (IM) and GC to determine the pathways involved in GC. A metabolic analysis of IM and tissue samples from 37 patients with GC was conducted using ultra-performance liquid chromatography with tandem mass spectrometry. Overall, 665 and 278 significant features were identified in the aqueous and 278 organic phases, respectively, using false discovery rate analysis, which controls the expected proportion of false positives among the significant results. sPLS-DA revealed a clear separation between IM and GC samples. Steroid hormone biosynthesis, tryptophan metabolism, purine metabolism, and arginine and proline metabolism were the most significantly altered pathways. The intensity of 11 metabolites, including N1, N2-diacetylspermine, creatine riboside, and N-formylkynurenine, showed significant elevation in more advanced GC. Based on pathway enrichment analysis and cancer stage-specific alterations, we identified six potential candidates as diagnostic biomarkers: aldosterone, N-formylkynurenine, guanosine triphosphate, arginine, S-adenosylmethioninamine, and creatine riboside. These metabolic differences between IM and GC provide valuable insights into gastric carcinogenesis. Further validation is needed to develop noninvasive diagnostic tools and targeted therapies to improve the outcomes of patients with GC.

Effect of endoscopic mucosal resection and endoscopic submucosal dissection on postoperative wound complications in patients with gastric cancer: A meta-analysis

Endoscopic submucosa dissection (ESD) allows complete excision of the whole lesion, which results in a higher percentage of complete excision and an improved quality of life by minimizing the amount of excision as opposed to an endoscopic mucosal resection (EMR). Although ESD is now being carried out in the majority of hospitals, ESD's possible complications (such as trauma and perforation) have given rise to doubts about ESD practices in patients with early-stage stomach cancer when deciding on therapy and reimbursement. This study was designed to evaluate the effectiveness and safety of ESD over EMR in treating early-stage stomach cancer. Four main databases have been searched, including EMBASE and published. The ROBINS-I tool suggested in the Cochrane Handbook has been applied to evaluate the quality of the chosen trials. It may better reflect the risk of bias in the included studies. The meta-analyses were carried out with ReMan 5.3, and the results were treated with endote. Seven cohort studies have been completed. Meta analysis indicated that EMR and ESD surgery did not differ significantly from each other in terms of postoperative haemorrhage (OR, 0.76; 95%CI, 0.56,1.04 p = 0.09); EMR, however, was associated with a lower rate of postoperative perforation than ESD surgery (OR, 0.36; 95%CI, 0.24,0.54 p < 0.0001). Taking into account that ESD and EMR did not differ significantly in the risk of wound bleeding, even though the risk of perforation is not likely to result in life-threatening illness. In the analysis of these data, however, the potential advantages of EMR might be greater than ESD.

Association between types of abdominopelvic cancer in patients with situs inversus total: Systematic review

BACKGROUND

Situs inversus is a rare congenital anatomical variant that involves a group of anomalies regarding the arrangement of intrathoracic and intraabdominal organs. Being able to find in the abdominal region the liver, gallbladder, inferior vena cava, and head of the pancreas and ascending colon on the left side of the abdomen, while on the right side there is the spleen, the stomach, the body of the pancreas, the ligament of Treitz, descending colon among others. In this same way, the thoracic organs, lungs and heart, are changed in their position in a mirror translocation.

METHODS

We systematically searched MEDLINE, Web of Science, Google Scholar, CINAHL, Scopus, and LILACS; the search strategy included a combination of the following terms: "Situs inversus," "Situs inversus totalis," "Cancer," "Neoplasm," "Abdominopelvic regions," and "clinical anatomy."

RESULTS

Within the 41 included studies, 46 patients with situs inversus who had cancer, in addition to being found in this organ and in these regions, we also found as a result that the majority of the studies in the research were in stage II; finally, no one study could assert the direct relationship between the situs inversus totalis and the cancer.

CONCLUSION

If our hallmarks could make us think that more exhaustive follow-up of the stomach and other organs should be carried out in these patients, there could also be other predisposing factors for cancer, which is why more studies are suggested to give future diagnostic and treatment guidelines treatment.

Risk factors for remnant gastric cancer after distal gastrectomy for gastric cancer: a retrospective database review

Background

The number of patients with remnant gastric cancer (RGC) following gastrectomy for gastric cancer (GC) is increasing due to the increasing number of patients undergoing function-preserving gastrectomy and improved outcomes for patients with GC. A few studies involving a small number of cases reported male sex, old age, differentiated type, tumor depth and synchronous multiple GC were associated with RGC development. However, the risk factors for RGC development had not been fully understood. This study aimed to examine the clinicopathological features, followed up patients with GC after they underwent distal gastrectomy (DG), and evaluated the potential risk factors for RGC development.

Methods

A retrospective database review of 438 patients who underwent DG for GC at a single institution, from 2006 to 2017, was conducted. We investigated the relationship of clinicopathological features, operative findings, and postoperative course with RGC development was estimated using Cox proportional hazard analysis. The cumulative incidences of RGC were calculated using the Kaplan-Meier method.

Results

We retrospectively analyzed 405 cases. The median patient age was 69 years, and the patient cohort consisted of 263 men and 142 women. The Billroth-I reconstruction method was used in 204 cases, Billroth-II method was used in 3 cases, and Roux-en Y method was used in 198 cases. RGC was diagnosed in 11 of the 405 patients. The median follow-up period was 5 years. The cumulative incidences of RGC calculated by the Kaplan-Meier method were 3.0%, 4.1%, and 10.5% at 5, 10, and 15 years after DG, respectively. During the initial surgery, differentiated type was significantly associated with RGC development [hazard ratio (HR): 4.71, 95% confidence interval (CI): 1.02-21.80, P=0.05]. Male sex (HR: 2.97, 95% CI: 0.64-13.75, P=0.16), old age (≥70 years) (HR: 2.72, 95% CI: 0.78-9.47, P=0.11), and synchronous multiple GC (HR: 1.31, 95% CI: 0.28-6.08, P=0.73) were not associated with RGC development.

Conclusions

Patients who have undergone DG for differentiated type GC were statistically significantly associated with developing RGC. Intensive endoscopic surveillance would be needed for the patients who underwent DG for differentiated type GC.

Individualized Endoscopic Surveillance for Metachronous Gastric Cancer After Endoscopic Submucosal Dissection: A Retrospective Observational Study

BACKGROUND/AIMS

Endoscopic submucosal dissection has been widely applied for curative resection of early gastric cancer or high-grade dysplasia, and metachronous gastric cancer is a major issue after endoscopic therapy. Here, we studied the recurrence patterns of metachronous gastric cancer and its correlation with the primary lesions.

MATERIALS AND METHODS

A total of 286 consecutive patients undergoing endoscopic submucosal dissection for early gastric cancer or high-grade dysplasia between March 2011 and March 2018 were retrospectively reviewed. Metachronous gastric cancer was defined as a new gastric cancer detected more than 1 year after endoscopic submucosal dissection.

RESULTS

During a median follow-up of 36 months, 24 patients developed metachronous gastric cancer. The 5-year cumulative incidence was 13.4% and the annual incidence was 24.3 cases per 1000 person-years. Subgroup analysis revealed that the third year after early gastric cancer resection and the fifth year after high-grade dysplasia resection were the predilection periods of metachronous gastric cancer. Correlation analysis suggested that the metachronous and primary lesions showed a significant correlation in cross-sectional position (C = 0.627, P = .027) but not in pathological characteristics (P > .05). When the primary lesions were located in the posterior walls, the metachronous lesions were prone to occur in the lesser curvatures (C = 0.494, P = .008) and the reverse was also true (C = 0.422, P = .029).

CONCLUSIONS

The predilection periods and common sites of metachronous gastric cancer are associated with the primary lesions. Meticulous individualized endoscopic surveillance after endoscopic submucosal dissection requires to be conducted, taking into account the characteristics of primary lesions.

Regional Lymph Node Metastasis Distribution in Resectable Middle-Third Gastric Cancer: A Cross-Sectional Study

Introduction Lymph node (LN) metastasis happens even in early gastric cancer (GC) even in LN stations that are not adjacent to the primary tumor. Total or subtotal gastrectomy (TG or sTG) can be performed in the middle third of the GC if the negative proximal margin is maintained. These procedures differed in the extent of LN dissection; therefore, oncology considerations must be taken into consideration when selecting the appropriate procedure. Methods This was a cross-sectional study involving 98 patients suffering from middle-third GC. The metastatic lymph nodes (mLN) ratio was calculated in each case by the ratio between the number of mLN and the number of total LNs retrieved. We compare the difference in the total LN retrieved, number of mLN, and rate of positive LN (N+) between the two groups TG and sTG. Results The majority of patients had advanced GC (82.7% pT2-4). About 65.3% of patients had metastasis LN. The events of LN metastasis and skipped LN metastasis happened even in tumors contained in the submucosal layer. The metastasis rates in each LN station were also increasing in correlation with the depth of tumor invasion. For LN station No. 2, 4sa, 10, 11d (which are not mandatory) in sTG, the rate of mLN was 0% for the pT1-3 tumor, regardless of tumor longitudinal location. The rate of mLN for each station was higher in adjacent stations of the tumor (No. 1-3-5-7 in lesser curvature, No. 4sb-4d-6 in greater curvature, No.1-3-4sb in the anterior wall, No. 3-7-12a in the posterior wall). The total LN retrieved, number of mLN, and rate of positive LN were statistically higher in the TG group compared to the sTG group. However, the mean mLN ratios between the two groups were comparable (p = 0.116). Conclusion In accordance with the macroscopic and microscopic characteristics, we observed a stratified distribution of mLN in the middle third of the GC. With these early results, sTG combined with standard lymphadenectomy was an acceptable treatment for T1-T3 middle-third GC in terms of mLN distribution. Total No. 4sb LN dissection might also be reserved in gastrectomy for T1-T3 GC.

Associate factors for endoscopic submucosal dissection operation time and postoperative delayed hemorrhage of early gastric cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) is a treatment for early gastric cancer with the advantages of small invasion, fewer complications, and a low local recurrence rate. However, there is a high risk of complications such as bleeding and perforation, and the operation time is also longer. ESD operation time is closely related to bleeding and perforation.

AIM

To investigate the influencing factors associated with ESD operation time and postoperative delayed hemorrhage to provide a reference for early planning, early identification, and prevention of complications.

METHODS

We conducted a retrospective study based on the clinical data of 520 patients with early gastric cancer in the Second Affiliated Hospital of Hainan Medical University from January 2019 to December 2021. The baseline data, clinical features, and endoscopic and pathological characteristics of patients were collected. The multivariate linear regression model was used to investigate the influencing factors of ESD operation time. Logistic regression analysis was carried out to evaluate the influencing factors of postoperative delayed hemorrhage.

RESULTS

The multivariate analysis of ESD operation time showed that the maximum lesion diameter could affect 8.815% of ESD operation time when other influencing factors remained unchanged. The operation time increased by 3.766% or 10.247% if the lesion was mixed or concave. The operation time increased by 4.417% if combined with an ulcer or scar. The operation time increased by 3.692% if combined with perforation. If infiltrated into the submucosa, it increased by 2.536%. Multivariate analysis of delayed hemorrhage after ESD showed that the maximum diameter of the lesion, lesion morphology, and ESD operation time were independent influencing factors for delayed hemorrhage after ESD. Patients with lesion ≥ 3.0 cm (OR = 3.785, 95%CI: 1.165-4.277), lesion morphology-concave (OR = 10.985, 95%CI: 2.133-35.381), and ESD operation time ≥ 60 min (OR = 2.958, 95%CI: 1.117-3.526) were prone to delayed hemorrhage after ESD.

CONCLUSION

If the maximum diameter of the lesion in patients with early gastric cancer is ≥ 3.0 cm, and the shape of the lesion is concave, or accompanied by an ulcer or scar, combined with perforation, and infiltrates into the submucosa, the ESD operation will take a longer time. When the maximum diameter of the lesion is ≥ 3.0 cm, the shape of the lesion is concave in patients and the operation time of ESD takes longer time, the risk of delayed hemorrhage after ESD is higher.

Comparisons of pathologic findings and outcomes of gastric cancer patients younger and older than 40: a propensity score matching study in a single center of Korea

Background and Aim

Gastric cancer (GC) is one of the most common cancers worldwide, with a high incidence rate in Korean men. However, comparative studies are scarce on the pathologic findings and treatment effects of GC in patients aged less than 40 years. We evaluated the characteristics and pathologic findings of GC patients aged younger and older than 40 years.

Methods

We retrospectively analyzed 2307 patients diagnosed with GC between January 2010 and May 2018. Eighty-eight (3.8%) and 2219 (96.2%) patients were younger and older than 40 years, respectively. The patients were divided into younger (n = 70) and older (n = 62) age groups through propensity matching.

Results

Overall, compared to the younger group, the older group (n = 2219) had a significantly higher proportion of male patients (66.7% vs 39.8%; P < 0.001) and patients who underwent endoscopic submucosal dissection (ESD) (2.3% vs 23.1%; P < 0.001). However, young patients more often underwent operations compared to older patients (78.4% vs 60.1%; P = 0.001). In the propensity-matched group, older patients more often showed differentiated carcinoma, including well-differentiated (5.7% vs 11.3%) and moderately differentiated (1.4% vs 32.3%). However, younger patients more often showed signet ring cell carcinoma (SRC) (70.0% vs 25.8%). In multivariate analysis, Helicobacter pylori infection (odds ratio, 12.643; 95% confidence interval, 1.068-1449.665; P = 0.044) independently correlated with SRC risk.

Conclusions

Patients below 40 years were more likely to undergo surgery compared to ESD, and pathologic findings were more common in SRC. Therefore, more active screening and H. pylori eradication are needed even in patients aged less than 40 years.

Nerves in gastrointestinal cancer: from mechanism to modulations

Maintenance of gastrointestinal health is challenging as it requires balancing multifaceted processes within the highly complex and dynamic ecosystem of the gastrointestinal tract. Disturbances within this vibrant environment can have detrimental consequences, including the onset of gastrointestinal cancers. Globally, gastrointestinal cancers account for ~19% of all cancer cases and ~22.5% of all cancer-related deaths. Developing new ways to more readily detect and more efficiently target these malignancies are urgently needed. Whereas members of the tumour microenvironment, such as immune cells and fibroblasts, have already been in the spotlight as key players of cancer initiation and progression, the importance of the nervous system in gastrointestinal cancers has only been highlighted in the past few years. Although extrinsic innervations modulate gastrointestinal cancers, cells and signals from the gut's intrinsic innervation also have the ability to do so. Here, we shed light on this thriving field and discuss neural influences during gastrointestinal carcinogenesis. We focus on the interactions between neurons and components of the gastrointestinal tract and tumour microenvironment, on the neural signalling pathways involved, and how these factors affect the cancer hallmarks, and discuss the neural signatures in gastrointestinal cancers. Finally, we highlight neural-related therapies that have potential for the management of gastrointestinal cancers.

Predicting Gastric Intestinal Metaplasia in a High-Risk Population

INTRODUCTION

Gastric intestinal metaplasia (GIM) is a precancerous lesion. It has a low prevalence rate in the United States. However, GIM is more common among non-White and immigrant populations. Harlem Hospital serves a community that includes predominantly African Americans, Hispanics, and immigrants from West Africa and Spanish-speaking Caribbean countries. This study aims to define the factors predicting GIM in this high-risk group as well as help define screening strategies for vulnerable populations.

METHODS

A total of 1351 patients who underwent endoscopic gastroduodenoscopy (EGD) and biopsy in 2018 and 2019 for any indication at Harlem Hospital were included in this study. Gastric biopsy specimens taken during the procedure were assessed for GIM by histopathology. Baseline demographics were collected, including age, sex, and ethnicity. Other information collected included risk factors for GIM such as Helicobacter pylori infection, smoking status, and the use of alcohol. Descriptive analysis was done and the Wilcoxon rank sum test and chi-squared test were used to test for associations. Multiple logistic regressions were used to assess the odds of independent factors associated with increased risk of GIM.

RESULTS

Of the 1351 patients reviewed, 106 had GIM for a prevalence of 8.0% (CI: 6.7%-9.6%, p < 0.001). Univariate analysis revealed older patients, males, history of smoking, alcohol, and H. pylori infection were significantly associated with GIM. Using multiple logistic regressions and adjusting for underlying risk factors, smoking (OR: 1.61, 95% CI: 1.00-2.570) and H. pylori infection (OR: 3.35, 95% CI: 2.18-5.15) continued to be significantly associated with increased risk of GIM; however, alcohol use was not significant after adjusting for other risk factors (OR: 1.10, 95% CI: 0.68-1.78). Hispanic risk for GIM was slightly higher than African Americans (OR: 1.17, 95% CI: 0.74-1.83). The predicted marginal effect of age on the odds of GIM was significant from age 40 and increased exponentially at age 50. By age 70, the odds of GIM were as high as 11% (95% CI: 8.3-13.6).

CONCLUSION

The prevalence of GIM in our population is significantly higher compared to reported cases in the United States. Age, male gender, H. pylori infection, and smoking significantly increase the risk of GIM. Given the high prevalence of GIM in our population, early endoscopic screening would play an important role in evaluating dyspepsia to diagnose GIM with or without H. pylori infection. We propose screening all at-risk ethnicities from age 40 years with EGD according to the Sydney System biopsy protocol. We believe this will ultimately decrease the incidence of gastric cancer death in these vulnerable populations of color.

Prognosis of patients with early gastric carcinoma treated by endoscopic submucosal dissection and risk factors for additional postoperative surgery

OBJECTIVE

To investigate the prognosis of patients with early gastric carcinoma (EGC) treated by endoscopic submucosal dissection (ESD) and the risk factors for additional postoperative surgery.

METHODS

A retrospective analysis was performed on 100 patients with EGC admitted to our hospital from January 2017 to May 2019. According to different surgical methods, patients were divided into the ESD (n=60) and endoscopic mucosal resection (EMR) groups (n=40). Clinical efficacy, perioperative indexes, incidence of complications and risk factors for additional postoperative surgery were compared.

RESULTS

The ESD group had evidently prolonged operation time (P<0.01) but similar intraoperative blood loss (P>0.05) as compared with the EMR group. In comparison to the EMR group, the gastrointestinal recovery time and length of stay in the ESD group were notably shorter (P<0.01), the rates of en bloc resection and complete resection of lesions were markedly higher (P<0.05), and the postoperative fever/infection rate was noticeably lower (P<0.05). The two surgical methods had no significant difference on the overall survival rate of patients (P=0.302). It was identified that the infiltration depth and the positive surgical margin were independent risk factors for postoperative additional surgery (all P<0.05). ROC analysis revealed that positive surgical margin was quite valuable in judging the need for additional postoperative surgery.

CONCLUSION

ESD can accelerate the postoperative recovery of patients with EGC, and positive surgical margin is independently tied to additional postoperative surgery in patients after ESD.

Sex-based differences in histology, staging, and prognosis among 2983 gastric cancer surgery patients

BACKGROUND

Few studies have been conducted on sex differences in the incidence, pathophysiology, and prognosis of gastric cancer (GC).

AIM

To analyze the differences in GC characteristics according to sex in patients who underwent surgical treatment for GC.

METHODS

A total of 2983 patients diagnosed with gastric adenocarcinoma who received surgical treatment at the Seoul National University Bundang Hospital between 2003 and 2017 were included. Baseline clinicopathological characteristics, histologic type of GC, overall and GC-specific survival rates, and associated risk factors were analyzed.

RESULTS

Among the 2983 patients, 2005 (67.2%) and 978 (32.8%) were males and females, respectively. The average age of the female group (59.36 years) was significantly younger than that of the male group (61.66 years; P < 0.001). Cancer of the gastric body (P < 0.001) and diffuse-type histology (P < 0.001) were more common in females than in males. This trend was more prominent in females younger than 60 years of age, with a significantly higher proportion of diffuse-type cancer than in the male group. Regardless of sex, diffuse-type GC was more common in younger patients, and the proportion of intestinal-type GC increased with age. The overall survival rate was significantly higher in females (P < 0.001). However, this difference disappeared for GC-specific survival (P = 0.168), except for the poor GC-specific survival rate in advanced-stage cancer (stage III or above) in females (P = 0.045). The risk factors for GC-related mortality were older age, upper location of GC, and diffuse- or mixed-type histology. In terms of comorbidities, more males died from diseases other than GC, including other malignancies such as lung cancer, hepatocellular carcinoma, and pancreatic cancer, and respiratory diseases such as interstitial lung disease and chronic obstructive pulmonary disease, while there were relatively more cardiovascular or cerebrovascular deaths in females.

CONCLUSION

Sex-based differences in GC were observed in clinicopathological features, including age at diagnosis, tumor location, histologic type, survival rate, and comorbidities.

pCLE highlights distinctive vascular patterns in early gastric cancer and in gastric diseases with high risk of malignant complications

Endoscopy is widely used to detect and diagnose precancerous lesions and gastric cancer (GC). The probe-based Confocal Laser Endomicroscopy (pCLE) is an endoscopic technique suitable for subcellular resolution and for microvasculature analyses. The aim of this study was to use pCLE to identify specific vascular patterns in high-risk and early stage GC. Mucosal architecture, vessel tortuosity, enlargements and leakage were assessed in patients with autoimmune gastritis and early gastric cancer (EGC). We were able to stratify gastritis patients by identifying distinct vascular profiles: gastritis was usually associated with increased vascularization characterized by a high number of tortuous vessels, which were also found in atrophic autoimmune disease. Leaky and tortuous vessels, distributed in a spatially irregular network, characterized the atrophic metaplastic mucosa. The mucosal vasculature of EGC patients displayed tortuous vessels, but unlike what detected in atrophic gastritis, they appeared patchy, as is in neoplastic gastric tissue. Very importantly, we detected vascular changes even in areas without lesions, supporting the contention that vascular alterations may provide a favorable microenvironment for carcinogenesis. This report confirms that pCLE is a valid endoscopic approach to improve the definition of patients with malignant lesions or at increased risk for GC by assessing vascular changes.

Comparison of biannual and annual endoscopic gastric cancer surveillance after endoscopic resection

BACKGROUND

Patients who received endoscopic resection (ER) for early gastric cancer (EGC) or high-grade dysplasia (HGD) are at high risk for the subsequent development of metachronous gastric cancer (MGC). This study aims to compare the detection rate and stage of MGC between biannual and annual endoscopic surveillance after ER of EGC or HGD.

METHODS

From September 2009 to August 2019, 859 patients who underwent ER for the treatment of EGC or HGD were analyzed, retrospectively. Patients received endoscopic surveillance twice a year (high-intensity group) or annually (low-intensity group) for 3 years.

RESULTS

A total of 521 patients were enrolled in this study (267 patients in the high-intensity group and 254 patients in the low-intensity group). During a mean follow-up of 5.3 ± 1.6 years, MGCs were found in 27 patients (16.9%) in the high-intensity group and 18 patients (7.1%) in the low-intensity group (P = 0.219). In patients with moderate to severe atrophy (Kimura-Takemoto grade C3 ~ O3), detection rates of MGC during 3 years from were 8.4% (16/191) and 2.2% (4/186), respectively (P = 0.007). Forty-four patients who received treatment for MGC, including endoscopic or surgical resection, were stage IA. Only one patient in the low-intensity group was diagnosed as stage IIIA advanced gastric cancer.

CONCLUSIONS

There was no significant difference in the detection rate of MGC between biannual and annual endoscopic surveillance after ER of EGC or HGD. However, biannual surveillance showed a higher detection rate during the first 3 years, especially for patients with moderate to severe gastric atrophy.

Characterization of Chronic Gastritis in Lynch Syndrome Patients With Gastric Adenocarcinoma

BACKGROUND

Gastric cancer is one of the Lynch syndrome (LS)-associated malignancies. Previous studies have suggested that LS patients with gastric cancer also had chronic atrophic gastritis in the background mucosa, but further histologic characterization was not attempted. This study aims to understand the histologic features of background chronic gastritis in LS patients with gastric adenocarcinoma.

METHODS

Eleven LS-associated gastric cancer cases were collected from five institutions. Demographics and clinical features were retrieved by review of medical charts. Pathological material was reviewed for tumor location and histologic type. In addition, non-neoplastic gastric mucosa was assessed for inflammation (chronic and active), atrophy, intestinal metaplasia (IM) in the antrum and body, as well as pyloric gland metaplasia and enterochromaffin-like (ECL) cell hyperplasia in the body.

RESULTS

Eleven LS patients with gastric cancer (four male and seven female) with a mean age of 63 years (range: 23 - 83) were included. Ten (90.9%) had personal cancer histories; however none of the patients had family history of gastric cancer. Eight (72.7%) patients underwent gastrectomy and three had endoscopic resection. Nine (81.8%) patients had tumor in the fundus and/or body and two had tumor present in the antrum. Seven (63.6%) cases were intestinal type or mixed type carcinoma, and the remaining four were signet ring cell carcinoma. Eight (of 11, 72.7%) patients had chronic gastritis, five (45.4%) had atrophy, and four (36.3%) had intestinal metaplasia. Four of five patients with both antrum and body mucosa available for evaluation (80%), demonstrated body-predominant chronic gastritis. Four patients had germline MLH1 alterations and all of these patients had chronic gastritis, including one Helicobacter pylori (H. pylori) gastritis and three H. pylori-negative gastritis.

CONCLUSIONS

None of LS patients with gastric cancer in our cohort had a family history of gastric cancer. Gastric adenocarcinomas in LS patients were primarily located in the fundus and/or body. Two-thirds of these tumors were of intestinal type and had a background chronic, H. pylori-negative gastritis. These results support a chronic atrophic gastritis with intestinal metaplasia-dysplasia-carcinoma sequence in LS-related gastric tumorigenesis, particularly in MLH1-mutated LS patients.